What is PQRS?

PQRS is a quality reporting program that uses negative payment adjustments to promote reporting of quality information by individual EPs and group practices. Those who do not satisfactorily report data on quality measures for covered Medicare Beneficiaries will be subject to a negative payment adjustment under PQRS.

The Penalty

The penalty for not reporting 2015 PQRS is 2% for solo providers and groups with 2-9 providers, and 4% for groups with 10 or more providers.

The penalty for not reporting 2016 PQRS is 2%. An additional penalty for the value-based modifier is 2% for solo providers and groups with 2-9 providers, and 4% for groups with 10 or more providers. These penalties will be incurred 2 years ahead; 2018 for 2016 reporting and 2019 for 2017 reporting.

How can I avoid this penalty?

EPs can avoid the 2017 PQRS negative payment adjustment by satisfactorily participating, according the following criteria: ◦ Report on at least 9 measures covering 3 NQS domains for at least 50% of the EP’s Medicare Part B FFS patients, one of them must be on the list of the cross cutting measures.
◦ EPs that submit quality data for only 1 to 8 PQRS measures for at least 50% of their patients or encounters eligible for each measure, OR that submit data for 9 or more PQRS measures covering less than 3 domains for at least 50% of their patients or encounters eligible for each measure will be subject to Measure Applicability Validation process.
◦ EPs that see 1 Medicare patient (face-to face encounter), but do not report on 1cross-cutting measure will be subject to MAV.
◦ Measures with a 0% performance rate will not be counted.

How do I report?

PQRS measures can be submitted through claims-based reporting or through registry-based reporting.

Claims-based reporting is readily accessible to EPs as it is a part of routine billing processes. When utilizing the PQRS mini-templates for documentation, the associated PQRS code will be placed on your claim.

However, it is not an option for PQRS group practices. Registry-based reporting must be used by group practices to submit PQRS measures to a CMS registry. The same QDC's used for claim-based reporting are added to encounter invoices but do not need to be sent with claims. Instead, the PQRS Report can export the PQRS measures to a compatible .csv file which can then be submitted to the registry.

Principles for Reporting QDCs via Claims

1. QDCs must be reported:
◦ On the claim(s) with the denominator billing code(s) that represents the eligible Medicare Part B PFS encounter.
◦ For the same beneficiary.
◦ For the same date of service (DOS).
◦ By the same eligible professional (individual rendering NPI) that performed the covered service, applying the appropriate encounter codes (ICD-9-CM, ICD-10-CM, CPT Category I or HCPCS codes). These codes are used to identify the measure's denominator.

2. QDCs must be submitted with a line-item charge of one penny ($0.01) at the time the associated covered service is performed.
◦ The submitted charge field cannot be blank.
◦ The line item charge should be $0.01 – the beneficiary is not liable for this nominal amount.
◦ Entire claims with a $0.01 charge will be rejected.
◦ When the $0.01 nominal amount is submitted to the MAC, the PQRS code line will be denied but will be tracked in the National Claims History (NCH) for analysis.

3. Claims may NOT be resubmitted for the sole purpose of adding or correcting QDCs.

4. The RA/EOB denial code N620 is your indication that the PQRS codes are valid for the 2015 PQRS reporting year.

NQF 0059: Diabetes: HBa1c Poor Control PQRS

PQRS # 001
Details: Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.Denominator Criteria: Diagnoses of DM 250. and age 18-75, E&M.Numerator Criteria: Patients who's most recent HbA1c level (performed during the measurement period) is > 9.0%.Applicable Code:
3046F HbA1c > 9
3046F w/ modifier 8P Not performed
3044F HbA1c < 7
3045F HbA1c 7 – 9Reporting Instructions: This must be reported once per reporting period.

NQF 0041: Screening for Influenza

PQRS # 110Details: Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.Denominator Criteria: All patients aged 6 months and older seen for a visit between October 1 and March 31 with an E&M.Numerator Criteria: Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization.Applicable Code:
G8482 Influenza administered or previously recorded
G8483 Not administered: Patient allergy or declined
G8484 Not administered: No reasonReporting Instructions: This must be done a minimum of once per reporting period.

NQF 0043: Pneumonia Vaccine

PQRS # 111Details: Pneumonia Vaccination Status for Older Adults: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.Denominator Criteria: Patients 65 years of age and older with a visit during the measurement period and with an E&M.Numerator Criteria: Patients who have ever received a pneumococcal vaccination.Applicable Code:
4040F Pneumonia vaccine administered or previously recorded
4040F w/ modifier 8P Not administered with no reasonReporting Instructions: This must be done a minimum of once per reporting period.

NQF 0417: Diabetic Foot and Ankle Care, Neurological Evaluation

PQRS # 126Details: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months.Denominator Criteria: All patients 18 years old and older with a diabetic diagnosis and a nail debridement, avulsion or E&M CPT during the reporting period.Numerator Criteria: Patients who had a lower extremity neurological exam performed at least once within 12 months.Applicable Code:
G8404 Lower extremity neurological exam performed and documented
G8405 Lower extremity neurological exam not performed
Other Performance Exclusion: Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure, for example patient bilateral amputee, patient has condition that would not allow them to accurately respond to a neurological exam (dementia, Alzheimer ́s, etc.), patient has previously documented diabetic peripheral neuropathy with loss of protective sensation.Reporting Instructions: This measure is to be reported a minimum of once per reporting period for patients with diabetes mellitus seen during the reporting period. Evaluation of neurological status in patients with diabetes to assign risk category and therefore have appropriate foot and ankle care to prevent ulcerations and infections ultimately reduces the number and severity of amputations that occur. See: Risk Categorization System

NQF 0416: Diabetic Foot and Ankle Care, Ulcer Prevention

PQRS # 127Details: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing.Denominator Criteria: All patients 18 years old and older with a diabetic diagnosis and a nail debridement, avulsion or E&M CPT during the reporting period.Numerator Criteria: Patients who were evaluated for proper footwear and sizing at least once within 12 months.Applicable Code:
G8410 Footwear evaluation performed and documented
G8415 Footwear evaluation was not performed
Other Performance Exclusion: G8416 Clinician documented that patient was not an eligible candidate for footwear evaluation measureReporting Instructions: This measure is to be reported a minimum of once per reporting period for patients with diabetes mellitus seen during the reporting period. Evaluation of neurological status in patients with diabetes to assign risk category and therefore have appropriate foot and ankle care to prevent ulcerations and infections ultimately reduces the number and severity of amputations that occur. See: Risk Categorization System

NQF 0421: BMI Screening and F/U

PQRS # 128Details: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30 kg/m2; Age 18 – 64 years BMI ≥ 18.5 and < 25 kg/m2.Denominator Criteria: All patients 18 years old and older with an E&M during the reporting period.Numerator Criteria: Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter.Applicable Code:
G8420 BMI within normal limits and no follow up
G8419 BMI outside of normal limits and no follow up
G8418 BMI below normal limits and follow up plan made with doctor
G8417 BMI above normal limits and follow up plan made with doctor
G8422 BMI not documented: patient not eligible
G8938 BMI documented outside normal limits: patient not eligible
G8421 BMI not documented with no reason givenReporting Instructions: This must be done a minimum of once per reporting period.

NQF 0419: Document Current Medications

PQRS # 130Details: Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional)supplements AND must contain the medications’ name, dosage, frequency and route of administration.Denominator Criteria: All visits for patients aged 18 years and older. An E&M code is required.Numerator Criteria: Eligible professional attests to documenting, updating or reviewing a patient’s current medications using all immediate resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administration.Applicable Code:
G8427 Patient medications have been reviewed
G8430 Patient not eligible
G8428 Patient medications not documentReporting Instructions: This measure is to be reported each visit during the 12 month reporting period.

NQF 0028: Preventative Care and Screening: Tobacco Use

PQRS # 226Details: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.Denominator Criteria: All patients aged 18 years and older and E&M visit.Numerator Criteria: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user.Applicable Code:
4004F Patient screened for tobacco use AND received tobacco cessation intervention
1036F Nonuser
4004F w/ modifier 8P Tobacco screening OR tobacco cessation intervention not performed, reason not otherwise specifiedReporting Instructions: This measure is to be reported once per reporting period.

Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up

PQRS # 317Details: Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.Denominator Criteria: All patients aged 18 years and older and E&M codes.Numerator Criteria: Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is pre-hypertensive or hypertensive.Applicable Code:
G8783 BP within normal limits, no follow-up required
G8950 Pre-Hypertensive or Hypertensive BP reading documented, AND the indicated follow-up is documented
G8784 BP reading not documented, documentation that the patient is not eligible
G8785 BP reading not documented, no reason given
G8952 Pre-Hypertensive or Hypertensive BP reading documented, indicated follow-up not documented, reason not givenReporting Instructions: This measure is to be reported a minimum of once per reporting period. This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The documented follow-up plan must be related to the current BP reading as indicated, example: “Patient referred to primary care provider for BP management”.

2015 Recommended Codes

The following measures were recommended in PQRS 2015 but are not recommended or not applicable for PQRS 2016.

NQF 0097: Medication Reconciliation

PQRS # 46Details: Medication Reconciliation: Percentage of patients aged 18 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented. Denominator Criteria: All patients 18 years of age and older discharged from any inpatient facility (eg, hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care and E&M.Numerator Criteria: Patients who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.Applicable Code:
1111F Medication Reconciliation Completed
1111F w/ modifier 8P Medication Reconciliation not CompletedReporting Instructions: This measure is to be reported at an outpatient visit occurring within 30 days of each inpatient facility discharge date during the reporting period.

NQF 0420: Pain Assessment

PQRS # 131Details: Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present.Denominator Criteria: All visits for patients aged 18 years and older. An E&M code is required.Numerator Criteria: Patient visits with a documented pain assessment using a standardized tool(s) AND documentation of a follow-up plan when pain is present. A documented outline of care for a positive pain assessment is required. This must include a planned follow-up appointment or a referral, a notification to other care providers as applicable OR indicate the initial treatment plan is still in effect.Applicable Code:
G8730 Pain (+) and a follow up has been documented
G8731 Pain negative and a follow up is not required
G8442 Pain not documented
G8939 Pain (+) and no follow up documented, patient not eligible
G8732 No pain documented, no reason
G8509 Pain (+), follow up not documentedReporting Instructions: This measure is to be reported each visit during the 12 month reporting period.

NQF 0101: Fall Risk Assessment

PQRS # 154Details: Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 monthsDenominator Criteria: All patients aged 65 years and older who have a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year). Documentation of patient reported history of falls is sufficient. And E&M codes.Numerator Criteria: Patients who had a risk assessment for falls completed within 12 months.Applicable Code:
3288F and 1100F Fall Risk Assessment documented and patient screened for future fall risk, documentation of two or more falls in the past year and any fall with injury in the past year
3288F w/ modifier 1P and 1100F Not completed for medical reason and documented in chart, history of fall in the past year 3288F w/ modifier 1P and 1100F w/ modifier 8P Not completed, no history of fall documented
3288F w/ modifier 8P and 1100F Not completed, documentation of falls in chart
Other Performance Exclusion: 1101F Patient screened for future fall risk; documentation of no falls in the past year or only one fall without injury in the past year.
If patient is not eligibile, report: 1101F with modifier 8P No documentation of fallsReporting Instructions: This measure is to be reported a minimum of once per reporting period.

NQF 0056: Diabetes: Foot Exam

PQRS # 163Details: Percentage of patients aged 18 – 75 years of age with diabetes who had a foot exam during the measurement period.Denominator Criteria: Patients aged 18 – 75 who had a diagnoses of diabetes with a visit during the measurement period, diagnoses of 250.XX and an E&M code.Numerator Criteria: Patients who received a foot exam (ie, visual inspection, sensory exam with monofilament and pulse exam) during the measurement period.Applicable Code:
G9226 Foot examination performed (includes examination through visual inspection, sensory exam with monofilament, and pulse exam – report when all 3 were completed)
G9225 Foot examination not performed, reason not givenReporting Instructions:
This measure is to be reported a minimum of once per reporting period for patients with diabetes mellitus seen during the reporting period.